Hedonic hunger, ultra-processed food consumption, and the moderating effects of impulsivity in pregnant individuals with body mass index ≥ 25.

Evidence suggests higher hedonic hunger (preoccupation with/desire to consume food for pleasure) is associated with greater ultra-processed food (UPF) consumption in non-pregnant individuals with higher, but not lower, self-report impulsivity or delay discounting. The current study tested the association between hedonic hunger and UPF consumption, and the moderating effects of self-report impulsivity and delay discounting, during pregnancy. Individuals (N = 220) with body mass index (BMI)≥25 completed the Power of Food Scale, 24-h dietary recalls, and Barratt Impulsiveness Scale-Version 11 in early-mid pregnancy. A subset enrolled in an ancillary study (n = 143) completed a Delay Discounting Task. Linear regression and moderation models covaried for age, gestational age, pre-pregnancy BMI, and socioeconomic status. The association between hedonic hunger and UPF consumption was nonsignificant (p = 0.47). Self-report impulsivity was not a significant moderator (p = 0.11), but delay discounting was (p = 0.01). Simple slopes analysis revealed a one-unit increase in hedonic hunger was associated with 7% lower UPF intake among participants with lower (M+1SD) delay discounting (p = 0.01) and 1% higher UPF intake among those with higher (M-1SD) delay discounting (p = 0.57). Findings contrast those from research with non-pregnant samples and indicate lower delay discounting may serve as a protective factor, associated with reduced UPF consumption at higher levels of hedonic hunger, during pregnancy.

A longitudinal investigation of breastfeeding planning, initiation, and duration among individuals with pre-pregnancy overweight or obesity.

Individuals with a body mass index (BMI)≥25 kg/m2 are less likely to initiate and continue breastfeeding than are those with BMIs<25. Given the intergenerational health benefits of breastfeeding, it is important to understand breastfeeding behaviors and their correlates among individuals with BMIs≥25. Thus, in an observational cohort with BMI≥25 (N = 237), we aimed to characterize longitudinal relationships among breastfeeding planning, initiation, and duration and their sociodemographic/clinical correlates and determine if pre-pregnancy BMI predicts breastfeeding planning, initiation, and duration. Breastfeeding behaviors, weight/BMI, and sociodemographic/clinical characteristics were assessed in early, mid, and late pregnancy, and at six-months postpartum. Most participants planned to (84%) and initiated (81%) breastfeeding, of which 37% breastfed for ≥6 months. Participants who were married, first-time parents, higher in education/income, and had never smoked tobacco were more likely to plan, initiate, and achieve ≥6 months of breastfeeding. Higher pre-pregnancy BMI was not associated with breastfeeding planning or initiation but was associated with lower adjusted odds of breastfeeding for ≥6 months relative to <6 months. Findings suggest that support aimed at extending breastfeeding among those with elevated pre-pregnancy BMI may be warranted. Future interventions should also address sociodemographic and clinical inequities in breastfeeding.

Furthering development of the Eating Disorder Examination-Pregnancy Version (EDE-PV): Exploratory factor analysis and psychometric performance among a community sample of pregnant individuals with body mass index ≥ 25.

Psychometrically sound measures of disordered eating during pregnancy are needed, particularly for pregnant individuals with body mass index (BMI) ≥ 25, who are at high risk for disordered eating attitudes/behaviors. We previously adapted the Eating Disorder Examination (EDE) for use among pregnant individuals with BMI ≥ 25. This study examined the factor structure of the EDE-Pregnancy Version (EDE-PV) in a community sample of pregnant individuals with BMI ≥ 25. The EDE-PV was administered to 257 pregnant individuals with pre-pregnancy BMI ≥ 25 between 12 and 20 weeks gestation. The EDE-PV factor structure was determined using an exploratory factor analysis with oblique geomin rotation, internal consistency coefficients were calculated, and convergent and discriminant validity of the EDE-PV factors were assessed. An 11-item, two-factor solution produced an acceptable model fit. The subscales did not replicate those of the EDE and were interpreted as Pregnancy Eating and Weight Change Concerns and Pregnancy Shape and Weight Concerns (αs=.67 and .85; ωs=.70 and .85, respectively). These subscales showed small-to-moderate, positive correlations with weight and psychosocial distress measures and differentiated between participants with and without lifetime histories of any eating disorder diagnosis, demonstrating adequate convergent and discriminant validity. The results indicate that the EDE-PV can more reliably identify factors associated with disordered eating attitudes/behaviors among pregnant individuals with BMI ≥ 25 compared to the EDE and support our call for the development and use of new and/or adapted measures to appropriately assess disordered eating during pregnancy.

The association between multidimensional sleep health and gestational weight gain.

BACKGROUND: Although poor sleep health is associated with weight gain and obesity in the non-pregnant population, research on the impact of sleep health on weight change among pregnant people using a multidimensional sleep health framework is needed. OBJECTIVES: This secondary data analysis of the Nulliparous Pregnancy Outcome Study: Monitoring Mothers-to-be Sleep Duration and Continuity Study (n = 745) examined associations between mid-pregnancy sleep health indicators, multidimensional sleep health and gestational weight gain (GWG). METHODS: Sleep domains (i.e. regularity, nap duration, timing, efficiency and duration) were assessed via actigraphy between 16 and 21 weeks of gestation. We defined 'healthy' sleep in each domain with empirical thresholds. Multidimensional sleep health was based on sleep profiles derived from latent class analysis and composite score defined as the sum of healthy sleep domains. Total GWG, the difference between self-reported pre-pregnancy weight and the last measured weight before delivery, was converted to z-scores using gestational age- and BMI-specific charts. GWG was defined as low (<-1 SD), moderate (-1 or +1 SD) and high (>+1 SD). RESULTS: Nearly 50% of the participants had a healthy sleep profile (i.e. healthy sleep in most domains), whereas others had a sleep profile defined as having varying degrees of unhealthy sleep in each domain. The individual sleep domains were associated with a 20%-30% lower risk of low or high GWG. Each additional healthy sleep indicator was associated with a 10% lower risk of low (vs. moderate), but not high, GWG. Participants with late timing, long duration and low efficiency (vs. healthy) profiles had the strongest risk of low GWG (relative risk 1.5, 95% confidence interval 0.9, 2.4). Probabilistic bias analysis suggested that most associations between individual sleep health indicators, sleep health profiles and GWG were biased towards the null. CONCLUSIONS: Future research should determine whether sleep health is an intervention target for healthy GWG.

Trajectories of Return to Cigarette Smoking Up to 1 Year Postpartum Among People Who Quit Smoking During Pregnancy.

INTRODUCTION: Previous work has identified predictors of relapse to smoking postpartum among parenting people who quit during pregnancy, but less is known about the time course of postpartum relapse. The study goals were to document patterns and correlates of smoking resumption among people who quit smoking during pregnancy and were motivated to remain abstinent. AIMS AND METHODS: We conducted a secondary analysis among participants in a randomized controlled trial of postpartum-specific smoking relapse prevention interventions who self-reported no smoking since the quit date to delivery (n = 280). Participants provided expired air samples of carbon monoxide, and completed self-report measures of mood, perceived stress, and demographic and pregnancy-related information. Timeline follow-back interviews were conducted at the end of pregnancy and 12-, 24-, and 52-weeks postpartum. RESULTS: The largest group (49.7% of participants) belonged to a trajectory reflecting abstinence across 1 year postpartum. Another 13% remained abstinent 5-6 months after delivery. However, one in five started to smoke consistently within 100 days after delivery, and 16% relapsed in a pattern that can be described as inconsistent smoking. Participants with more prior quit attempts and those who smoked more cigarettes prior to their quit attempt were more likely to relapse within 100 days of delivery. CONCLUSIONS: The first 3 months postpartum represent a critical window for relapse prevention, given that most individuals who relapsed did so in the first 100 days or so after delivery. Assessing prior smoking history can help identify pregnant people who will need additional support in the early postpartum period. IMPLICATIONS: Relapse to smoking during the year after childbirth is common, but the time course of relapse after delivery is poorly understood. This study provides evidence for 4 distinct trajectories of relapse, and highlights variables linked to early relapse that may improve efforts to target and time intervention efforts. Specifically, assessing age at initiation, quantity of tobacco use prior to quit attempt, and number of previous quit attempts will identify pregnant people at greatest risk of early relapse. These findings also suggest that additional support early in the postpartum period is crucial for most people in the postpartum who will relapse.

The association between preconception loss of control over eating and depressive symptom trajectories from childhood through first pregnancy.

OBJECTIVE: Loss of control over eating (LOC) during pregnancy impacts prenatal health and often co-occurs with depressive symptoms. However, the role of depression history as a risk factor for LOC prior to pregnancy is unclear; information that is essential for effective prenatal health promotion. We examined the association between trajectories of depressive symptoms from childhood to first pregnancy and preconception LOC. METHOD: Participants (N = 1031) were predominantly Black, first-time mothers enrolled in the population-based Pittsburgh Girls Study. LOC and depressive symptoms were measured annually. Pre-pregnancy height and weight, and gestational weight gain data were abstracted from medical records. RESULTS: There was a significant difference in age of first conception for Black and White individuals (t = 8.73, df = 976, p < .001). Latent class analysis revealed four and three classes of depressive symptom trajectories for Black and White individuals, respectively. In the entire sample, the high-changing and moderate-decreasing classes of depressive symptoms were each associated with lifetime, in preconception year and not in preconception year, LOC (X2 = 56.7, p < .001). DISCUSSION: High levels of lifetime depressive symptoms may increase vulnerability to future LOC prior to first pregnancy, suggesting potential targets for interventions to improve maternal health. PUBLIC SIGNIFICANCE: Both depression history and disordered eating behaviors are known to influence prenatal health. The present study revealed associations between high levels of depressive symptoms from childhood through first pregnancy and loss of control over eating that included the year prior to conception. Results highlight potential targets for preconception interventions with relevance for future prenatal health.

Loss of control eating during pregnancy is associated with excessive gestational weight gain among individuals with overweight and obesity.

BACKGROUND: Excessive gestational weight gain (GWG) predicts negative health outcomes among individuals with overweight or obesity. Loss of control eating (LOC), the ingestion of food associated with being unable to control eating, is the core psychopathology of binge eating disorders. We evaluated the contribution of LOC to GWG among pregnant individuals with prepregnancy overweight/obesity. METHODS: In a prospective longitudinal study, individuals with prepregnancy BMI ≥ 25 (N = 257) were interviewed monthly to assess LOC and reported demographic, parity, and smoking information. GWG was abstracted from medical records. RESULTS: Among individuals with prepregnancy overweight/obesity, 39% endorsed LOC prior to or during pregnancy. After adjusting for factors that have previously been linked to GWG, LOC during pregnancy, uniquely predicted higher GWG and greater likelihood of exceeding GWG recommendations. Participants with prenatal LOC gained 3.14 kg (p = 0.03) more than did those without LOC during pregnancy and 78.7% (n = 48/61) exceeded IOM guidelines for GWG. The frequency of LOC episodes was also associated with greater weight gain. CONCLUSIONS: Prenatal LOC is common among pregnant individuals with overweight/obesity and predicts greater GWG and increased likelihood of exceeding IOM GWG guidelines. LOC may represent a modifiable behavioral mechanism to prevent excessive GWG among individuals at risk for adverse pregnancy outcomes.

Association between labor and delivery pain and postpartum pain with symptoms and clinical diagnosis of postpartum depression in patients with overweight and obesity.

PURPOSE: Childbirth pain has been associated with the risk for postpartum depression. However, existing studies have been limited by the use of depression screening tools as outcomes, and none to date have used a structured clinical interview for DSM-V (SCID), which is considered the gold standard for psychiatric diagnoses. This study aimed to quantify the relationships between labor and postpartum pain and postpartum depression diagnosis detected by SCID, as well as depression symptoms detected by the Center for Epidemiological Studies Depression Scale (CESD) screening tool, among a high-risk cohort. METHODS: The study was a secondary analysis of a prospective observational study of a cohort of women enriched for high risk for depression, i.e., pregnant women originally enrolled in a prospective study investigating factors leading to excessive gestational weight gain. Subjects were assessed prospectively for depression using both SCID and CESD at the third trimester and at 6 months postpartum. Overweight and obesity were defined as pre-gravid body mass index (BMI) ≥ 25 kg/m2. Both vaginal and cesarean deliveries were included in the cohort. Pain scores (0-10 numeric rating scale) during childbirth and after delivery were correlated with CESD and SCID. Propensity score matching was performed with propensity groups defined as those with low-moderate postpartum pain and those with high postpartum pain. The relationships between pain measures and 6-month postpartum depression diagnosis by SCID, and between pain measures and 6-month postpartum depression symptoms by CESD, were assessed by unweighted logistic regression and by logistic regression weighted by propensity score derived by average treatment effect (ATE) adjusted for baseline covariates. RESULTS: There were 237 subjects in the cohort for analysis. Labor and postpartum pain were not associated with depression diagnosis by SCID at 6 months postpartum. However, postpartum pain, but not labor pain, was associated with depressive symptoms on the CESD at 6 months postpartum. Women with higher maximum postpartum pain scores had significantly higher odds of developing clinically significant postpartum depressive symptoms at 6 months, compared to those with lower pain scores in the unweighted model (OR: 1.3, 95% CI 1.0, 1.5; P = 0.005) and ATE-weighted models (OR: 1.2, 95% CI 1.0, 1.5; P = 0.03). Consistent with prior work, SCID and CESD were strongly associated, and 92.9% (13/14) of participants with postpartum depression diagnosis by 6-month SCID also showed high CESD symptomology, P < 0.0001). CONCLUSIONS: Although labor and postpartum pain were not associated with clinical diagnosis of depression (SCID) at 6 months postpartum, postpartum pain was linked to 6-month postpartum depression symptoms. Depressive symptoms are more likely to be exhibited in women with higher postpartum pain, potentially reflecting poorer birth recovery. The contribution of postpartum pain and depressive symptoms to overall patterns of poor recovery after childbirth should be assessed further.

Sleep characteristics modify the associations of physical activity during pregnancy and gestational weight gain.

OBJECTIVE: Excessive gestational weight gain (eGWG) is associated with adverse long-term maternal outcomes. Most lifestyle interventions that incorporate physical activity have been ineffective at reducing eGWG. The purpose of this study was to determine if sleep modified the relationships between physical activity change from the 2nd to 3rd trimester and the odds of excessive gestational weight gain (eGWG). METHODS: This was a secondary data analysis of a prospective cohort study of pregnant birthing people with overweight or obesity (n = 105). We estimated physical activity energy expenditure (PAEE) in the 2nd and 3rd trimesters of pregnancy and sleep characteristics (i.e., sleep quality, daytime dysfunction, sleep efficiency, sleep duration) in the 2nd trimester of pregnancy with validated measures. We used regression models with sleep and PAEE change (increase/stable vs. decrease) interaction terms to examine the impact of sleep on PAEE change and eGWG. RESULTS: Mean GWG was 37.02 ± 16.76 lbs. and 80% of participants experienced eGWG. Eighteen percent of participants increased their PAEE from the 2nd to the 3rd trimester. Increasing (vs. decreasing) PAEE was associated with lower log-odds of eGWG only among participants that slept at least 8 h/night (p = 0.06), had at least 85% sleep efficiency (p = 0.03), or reported less daytime dysfunction (p = 0.08). Sleep quality did not moderate the association between PAEE change and eGWG. CONCLUSIONS: Weight management interventions in pregnancy should consider screening for and addressing poor sleep in the second trimester.

Cohort Study of Cannabis Use History and Perinatal Cigarette Use Among Overweight and Obese Women.

OBJECTIVES: In non-pregnant populations, cannabis use and cannabis use disorder (CUD) have been linked to tobacco use and less successful quit attempts. We compared perinatal cigarette use in women across 3 groups: never used cannabis (No CU group); used cannabis but did not meet CUD criteria (CU group); history of CUD (CUD group). METHODS: Interviews with 257 pregnant women with overweight/obesity (M age = 28 years; 52% white) were conducted for a study of eating behavior in Western Pennsylvania from 2012-2016. Tobacco use was assessed early in pregnancy (< 20 weeks gestation), late in pregnancy (34-38 weeks gestation) and 6 months postpartum. CUD was measured with the Structured Clinical Interview for DSM-IV (SCID). Data relevant to the proposed analyses were available for 252 women. Generalized mixed effect models were used to predict perinatal cigarette use based on cannabis use group, time and their interaction, adjusting for age, race, education, income, parity, and mood/anxiety disorder. RESULTS: Forty-eight percent of participants reported prior cannabis use and 15% were diagnosed with lifetime CUD. History of cannabis use predicted cigarette smoking in early pregnancy (OR 11.12, CI 3.27-37.85), late pregnancy (OR 6.55, CI 1.70-25.27), and 6 months postpartum (OR 7.57, CI 2.72-21.07), regardless of CUD. CONCLUSIONS: A history of CUD did not appear to confer additional risk for perinatal cigarette use. Given increasing rates of cannabis use among pregnant women, these results highlight the importance of addressing history of cannabis use in conjunction with tobacco use to improve smoking cessation efforts.

An exploratory investigation of predictors of outcome in face-to-face and online cognitive-behavioural therapy for bulimia nervosa.

OBJECTIVE: Cognitive-behavioural therapy (CBT) delivered face-to-face and via the internet reduces bulimia nervosa (BN) symptoms. However, our empirical understanding of factors affecting patient outcomes is limited. METHOD: Using data from a randomised, controlled trial comparing internet-based (CBT4BN, n = 78) with face-to-face (CBTF2F, n = 71) group CBT (97% female, M = 28 years), we examined general treatment (across conditions) and modality-specific predictors of end-treatment and 1-year outcomes (abstinence, binge-eating frequency, purging frequency). RESULTS: Improved eating disorder-related quality of life (EDQOL) during treatment and follow-up predicted abstinence at end-treatment and 1-year assessments. Improved EDQOL, disordered eating cognitions, and anxiety symptoms predicted less frequent binge eating and purging. Previous CBT and being employed predicted more frequent binge eating and purging at both assessments. Higher self-transcendence and self-directedness predicted less frequent binge eating. More severe binge eating and purging at baseline and end-treatment predicted more frequent binge eating and purging at subsequent assessments. Improved EDQOL was more strongly associated with positive outcome in CBT4BN; improved depressive symptoms and health-related QOL predicted positive outcome in CBT4BN but not CBTF2F. DISCUSSION: Symptom improvement and certain character traits predicted positive outcome, whereas more severe presentation and prior CBT experience predicted poorer outcome. Consideration of intreatment symptom improvement may facilitate care recommendations, particularly for internet-based modalities.

Documenting the course of loss of control over eating prior to, during and after pregnancy among women with pre-pregnancy overweight and obesity.

OBJECTIVE: Loss of control over eating (LOC) is common among women, particularly those with overweight and obesity (OV/OB), and predicts weight gain. Given the importance of understanding weight and eating behaviors during pregnancy, we sought to characterize LOC across pregnancy and the postpartum period among women with pre-pregnancy OV/OB. METHODS: Pregnant women (N = 257; 28.44 ± 5.48 years old) with self-reported OV/OB prior to pregnancy were interviewed using a pregnancy-adapted version of the Eating Disorder Examination (EDE-PV). Pre-pregnancy LOC was retrospectively assessed during the first trimester and then prospectively assessed monthly throughout pregnancy and postpartum over the course of seven assessments. RESULTS: Rates of LOC were significantly higher during pregnancy compared to prior to ( χ12 =44.845, p < .01) and after ( χ12 =36.379, p < .01) pregnancy, with 37% (n = 95) of women reporting ≥1 LOC episode during pregnancy. LOC during pregnancy was associated with higher likelihood of LOC postpartum. Higher age (OR = 1.084, p = .04) and identifying as a minority (OR = 0.344, p = .02) was associated with greater likelihood of experiencing LOC during pregnancy only. DISCUSSION: LOC during pregnancy is common among women with pre-pregnancy OV/OB, suggesting that screening and intervention for LOC during pregnancy may be warranted. Future research is necessary to examine the relationship between LOC during pregnancy and maternal and infant health outcomes.

Disparities in disordered eating between gender minority and cisgender adolescents.

OBJECTIVE: Adolescence is a developmental period of increased risk for disordered eating. Gender minority adolescents (GMAs), or those whose gender identity does not align with their sex assigned at birth, may experience body image concerns related to unique gender-related stressors. GMAs may use disordered eating to affirm a feminine, masculine, or nonbinary gender identity. However, little is known about differences in disordered eating between GMAs and cisgender adolescents. Therefore, this study had two primary goals: (a) to compare disordered eating between GMAs and cisgender adolescents by examining the role of gender identity and sex assigned at birth; and (b) within GMAs, to examine associations between gender identity congruence and disordered eating. METHOD: A large U.S. sample of GMAs and cisgender adolescents (n = 1,191 GMAs; 919 cisgender; Mage = 15.93 years) reported their disordered eating on an anonymous online survey. RESULTS: A MANOVA revealed a significant interaction between gender identity and sex assigned at birth. Follow-up ANOVAs demonstrated that purging, caloric restriction, excessive exercise, and muscle building differed as a function of gender identity and sex assigned at birth. Among GMAs, a multiple multivariate regression model demonstrated that disordered eating was lower among participants who reported greater gender identity congruence. DISCUSSION: GMAs should not be considered a homogenous group, as differences in gender identity may lead to the internalization of different appearance ideals and disparate eating disorder symptomatology. Results suggest that clinicians working with GMAs consider the unique body image concerns that could accompany a specific gender identity.

Demographic, Pregnancy-Related, and Health-Related Factors in Association with Changes in Sleep Among Pregnant Women with Overweight or Obesity.

BACKGROUND: Women with prepregnancy overweight/obesity are at high risk for obstetric complications and cardiometabolic disease. Poorer sleep quality is associated with obesity in non-pregnant individuals and, during pregnancy, poor sleep predicts negative obstetric and health outcomes. This study examined sleep patterns among women with overweight/obesity and factors associated with different sleep trajectories during pregnancy. METHODS: Women (N = 146, 17-40 years old) with a prepregnancy body mass index ≥ 25 kg/m2 were recruited during early pregnancy. Participants reported demographic information and completed the Pittsburgh Sleep Quality Index (PSQI) at up to six monthly assessments, with the first assessment occurring between 12 and 20 weeks gestation and the final assessment between 35 weeks gestation and delivery. PSQI scores > 5 indicate "poor sleep." RESULTS: On average, women's PSQI scores were 6.66 ± 3.58 in the first half of pregnancy and were significantly higher (worse) at the end of pregnancy (t(644) = 4.55, p < 0.001), with the greatest change occurring in the third trimester (t(636.3) = 3.72, p < 0.001). Women who currently smoked had poorer sleep than women who did not currently smoke (t(1) = 2.29, p = 0.02). Prepregnancy weight status, age, parity, race, education, and income were not significantly associated with sleep changes (t(1) < 1.76, ps > 0.08). The percentage of women with PSQI scores > 5 (the threshold for poor sleep quality) was 37-63% across assessments, with the greatest increase occurring during the third trimester (t(633) = 2.92, p = 0.004). CONCLUSIONS: Sleep quality worsens during the third trimester and is associated with current smoking. Future studies of sleep during pregnancy should examine health outcomes among women with overweight/obesity and early intervention to mitigate sleep disturbances as pregnancy progresses.

Factors associated with early gestational weight gain among women with pre-pregnancy overweight or obesity.

The present study aimed to document the prevalence of and identify factors associated with excessive gestational weight gain (GWG) in early pregnancy among women with pre-pregnancy overweight or obesity. Women with pre-pregnancy overweight or obesity (n = 247) were recruited between 12 and 20 weeks of gestation and completed questionnaires and were weighed to estimate early GWG. Nearly one-third of women met (17%, n = 42) or exceeded (13%, n = 33) guidelines for total GWG in early pregnancy. Univariate analyses showed race, income, and pre-pregnancy weight status to be significantly related to GWG category in early pregnancy (p < .009). Only race and pre-pregnancy weight status remained significant in a multivariate model, with Black women and women with pre-pregnancy obesity having higher odds of having met or exceeded guidelines for total GWG in early pregnancy compared with White women and women with pre-pregnancy overweight (p < .04). These findings highlight the need for early intervention to reduce weight-related complications among pregnant women.Impact statementWhat is already known on this subject? Women with pre-pregnancy overweight or obesity who gain excessive gestational weight early in pregnancy are at unique risk for pregnancy complications and adverse birth outcomes.What do the results of this study add? The present study adds to a growing body of literature documenting that a notable amount of women are gaining excessive gestational weight early in pregnancy. The present study further documents that Black women and women with pre-pregnancy obesity are at particular risk of gaining excessive gestational weight early in pregnancy.What are the implications of these findings for clinical practice and/or further research? Additional work examining modifiable risk factors, particularly among Black women and women with pre-pregnancy obesity, that contribute to excessive gestational weight gain (GWG) in the first half of pregnancy is warranted and will be necessary to inform interventions aimed at promoting weight loss during the preconception and interconception periods or encouraging appropriate GWG across the entire course of pregnancy.

Depressive Symptoms Assessed Near the End of Pregnancy Predict Differential Response to Postpartum Smoking Relapse Prevention Intervention.

BACKGROUND: Depressive symptoms are prevalent during pregnancy and the postpartum period and affect risk for smoking relapse. Whether and how depression affects response to postpartum interventions designed to sustain smoking abstinence is unknown. PURPOSE: We examined end-of-pregnancy depressive symptoms as a moderator of response to two postpartum-adapted smoking relapse prevention interventions. METHODS: Women (N = 300) who quit smoking during pregnancy were randomized to receive either a postpartum intervention focused on psychosocial factors linked to postpartum smoking (Strategies to Avoid Returning to Smoking [STARTS]) or an attention-controlled comparison intervention (SUPPORT). Women completed the Edinburgh Postnatal Depression Scale at the end of pregnancy. Smoking status was biochemically assessed at the end of pregnancy and at 12, 24, and 52 weeks postpartum. RESULTS: End-of-pregnancy depressive symptoms moderated response to postpartum smoking relapse prevention interventions (χ2 = 10.18, p = .001). After controlling for variables previously linked to postpartum smoking relapse, women with clinically significant end-of-pregnancy depressive symptoms (20%) were more likely to sustain abstinence through 52 weeks postpartum if they received STARTS. In contrast, women with few end-of-pregnancy depressive symptoms were more likely to sustain abstinence through 52 weeks postpartum if they received SUPPORT. Changes in the psychosocial factors addressed in the STARTS intervention did not mediate this moderation effect. CONCLUSION: Assessment of end-of-pregnancy depressive symptoms may help determine success following postpartum smoking relapse prevention interventions. Women with elevated end-of-pregnancy depressive symptoms benefited from postpartum relapse prevention intervention tailored to their psychosocial needs, while those with few symptoms were more successful in postpartum intervention that used standard behavioral components. CLINICAL TRIAL REGISTRATION: NCT00757068.

Healthcare provider advice on gestational weight gain: uncovering a need for more effective weight counselling.

Limited research has examined the factors related to knowledge of gestational weight gain (GWG) recommendations and the receipt of advice from healthcare providers regarding GWG recommendations among women with pre-pregnancy overweight/obesity. Women with pre-pregnancy overweight/obesity (N = 191) reported the amount of gestational weight they believed they should gain and that healthcare providers advised them to gain. Only 24% (n = 46) of women had a correct knowledge of GWG recommendations. Women were less likely to have a correct knowledge of GWG recommendations if they had pre-pregnancy obesity, were of a minority race, or were socioeconomically disadvantaged. Meanwhile, only 17% (n = 32) of women reported being correctly advised about GWG recommendations by healthcare providers. There were no differences between women who did and did not report being correctly advised about GWG recommendations from healthcare providers. These findings indicate that women with pre-pregnancy overweight/obesity lack knowledge of GWG recommendations and report being incorrectly advised about GWG recommendations from healthcare providers. Impact statement What is already known on this subject? Extant literature indicates that women's knowledge of gestational weight gain (GWG) recommendations and women's receipt of information from their healthcare providers regarding GWG recommendations are predictive of meeting the Institute of Medicine guidelines for GWG. What do the results of this study add? Findings from the present study indicate that the majority of women with pre-pregnancy overweight/obesity lack knowledge of GWG recommendations and report that education on GWG recommendations from healthcare providers is an aspect of their prenatal care that is largely insufficient. Although there were no differences between women who did and did not report being correctly advised about GWG recommendations by healthcare providers, women were less likely to have a correct knowledge of GWG recommendations if they had pre-pregnancy obesity, were of a minority race, or were socioeconomically disadvantaged. What are the implications of these findings for clinical practise and/or further research? These findings highlight a need for more effective tailoring of prenatal care to ensure that women receive accurate advice from healthcare providers regarding GWG recommendations.

CBT4BN: A Randomized Controlled Trial of Online Chat and Face-to-Face Group Therapy for Bulimia Nervosa.

OBJECTIVE: Although cognitive-behavioral therapy (CBT) represents the first-line evidence-based psychotherapy for bulimia nervosa (BN), most individuals seeking treatment do not have access to this specialized intervention. We compared an Internet-based manualized version of CBT group therapy for BN conducted via a therapeutic chat group (CBT4BN) to the same treatment conducted via a traditional face-to-face group therapy (CBTF2F). METHOD: In a two-site, randomized, controlled noninferiority trial, we tested the hypothesis that CBT4BN would not be inferior to CBTF2F. A total of 179 adult patients with BN (2.6% males) received up to 16 sessions of group CBT over 20 weeks in either CBT4BN or CBTF2F, and outcomes were compared at the end of treatment and at the 12-month follow-up. RESULTS: At the end of treatment, CBT4BN was inferior to CBTF2F in producing abstinence from binge eating and purging. However, by the 12-month follow-up, CBT4BN was mostly not inferior to CBTF2F. Participants in the CBT4BN condition, but not CBTF2F, continued to reduce their binge-eating and purging frequency from the end of treatment to the 12-month follow-up. CONCLUSIONS: CBT delivered online in a group chat format appears to be an efficacious treatment for BN, although the trajectory of recovery may be slower than face-to-face group therapy. Online chat groups may increase accessibility of treatment and represent a cost-effective approach to service delivery. However, barriers in service delivery such as state-specific license and ethical guidelines for online therapists need to be addressed.

Do Psychiatric Disorders or Measures of Distress Moderate Response to Postpartum Relapse Prevention Interventions?

INTRODUCTION: Most women who quit smoking during pregnancy will relapse postpartum. Interventions for sustained postpartum abstinence can benefit from understanding prenatal characteristics associated with treatment response. Given that individuals with psychiatric disorders or elevated depressive symptoms have difficulty quitting smoking and that increases in depressive symptoms prenatally are common, we examined the relevance of psychiatric diagnoses, prenatal depressive symptoms, and stress to postpartum relapse prevention intervention response. METHODS: Pregnant women (N = 300) who quit smoking during pregnancy received intervention (with specialized focus on mood, weight, and stress [STARTS] or a comparison [SUPPORT]) to prevent postpartum relapse. As previously published, nearly one-third and one-quarter of women achieved biochemically-confirmed sustained abstinence at 24- and 52-weeks postpartum, with no difference in abstinence rates between the interventions. Women completed psychiatric interviews and questionnaires during pregnancy. Smoking was assessed in pregnancy, and 24- and 52-weeks postpartum. RESULTS: Psychiatric disorders did not predict sustained abstinence or treatment response. However, treatment response was moderated by end-of-pregnancy depressive symptoms (χ2 = 9.98, p = .002) and stress (χ2 = 6.90, p = .01) at 24- and 52-weeks postpartum and remained significant after including covariates. Women with low distress achieved higher abstinence rates in SUPPORT than in STARTS (37% vs. 19% for depressive symptoms; 36% vs. 19% for stress), with no difference for women with high symptoms. CONCLUSIONS: Prenatal depressive symptoms and stress predicted differential treatment efficacy in women with low symptoms, not in women with high symptoms. Diagnostic history did not predict treatment differences. Future research to address prenatal distress may help tailor postpartum relapse prevention interventions. IMPLICATIONS: We examined prenatal history of psychiatric disorders and psychiatric distress as moderators of response to postpartum smoking relapse prevention intervention that either included or did not include added content on mood, stress, and weight concerns. For women with lower psychiatric distress, the added focus is not necessary, as these women achieved greater sustained abstinence in the less-intensive treatment. Understanding which women need which level of care to sustain abstinence can help allocate resources for all postpartum former smokers. These findings underscore the importance of perinatal symptom monitoring and promoting behavioral health more broadly in pregnant and postpartum women.

The Influence of Smoking on Breast feeding Among Women Who Quit Smoking During Pregnancy.

INTRODUCTION: Understanding factors related to breast-feeding intention, initiation, duration, and weaning among women who quit smoking as a result of pregnancy may inform interventions to increase breast-feeding rates among women who smoke. METHODS: Women (N = 300) who quit smoking as a result of pregnancy and enrolled in a postpartum relapse prevention trial were interviewed about breast-feeding intention prior to delivery. Breast-feeding initiation, duration, reasons for weaning, and relapse to smoking were assessed at 12-weeks postpartum. RESULTS: The majority of pregnant former smokers intended to breastfeed (68%), and actual rates of breast feeding were higher (74%). Among women who initiated breast feeding, weaning before 2 months was common (41%). For most women (69%), smoking had no effect on breast-feeding decisions. Among the 31% of women who reported that smoking influenced their feeding decisions, 83% indicated that they did not smoke or decreased smoking frequency in order to breastfeed while 17% did not breastfeed or quit breast feeding in order to smoke. Women who decided to forgo breast feeding to smoke were significantly more likely to have a high school education or less (p < .001) and to be African American (p < .0001) than those who had other reasons not to breastfeed. CONCLUSIONS: Most women who quit smoking during pregnancy initiate breast feeding, and the majority report smoking did not influence feeding decisions. Importantly, among women for whom smoking did influence feeding decisions, most reported changing smoking behavior to enable breast feeding. Interventions to increase breast-feeding initiation and duration may decrease postpartum relapse and improve maternal and infant health. IMPLICATIONS: This study extends the literature on women's perception of the influence of smoking on breast feeding by assessing breast-feeding intent, initiation, duration, and reasons for weaning longitudinally among women who quit smoking as a result of pregnancy. The results support a need for additional research to determine the effectiveness of breast feeding supports as a component of interventions to reduce postpartum smoking relapse.